Posted January 5, 2023
Diagnosis Specificity & Top Diagnosis Codes by Clinical Grouping
Your organization’s diagnosis coding practices play an important role in your agency’s success under the Patient-Driven Groupings Model (PDGM). PDGM captures the comorbidity adjustment based on comorbid diagnoses that are captured for the patient. Depending on the coding, a 30- day period may receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment. With 22 low co-morbidity adjustment subgroups and 91 high comorbidity subgroups for CY2023, taking the right steps to gather specificity is crucial.
Low comorbidity adjustment occurs when there is a specific diagnosis associated with higher resource use, such as Cerebrovascular Disease and Sequelae of Strokes. An agency would not receive a low comorbidity adjustment for including a diagnosis of cerebrovascular disease, unspecified. However, if the steps were taken to determine the specific type of cerebrovascular disease, such as cerebral ischemia, this would result in at least a low comorbidity adjustment for the period.
High comorbidity adjustment occurs when there are two or more secondary diagnosis included in the coding that may interact with each other resulting in higher resource use.
Importance of specificity
Let’s consider a patient who has a comorbid diagnosis of Unspecified Chronic Bronchitis and a Non-Chronic Pressure Ulcer of the Left Ankle. Unspecified Chronic Bronchitis does not provide any co-morbidity adjustment, while the Non-Chronic Pressure Ulcer of the Left Ankle falls into a Skin 3 comorbidity group. In this scenario there would be no comorbidity adjustment. However, if a more specific diagnosis of Non-Obstructive Chronic Bronchitis was documented, then this condition would fall into the Respiratory 4 comorbidity group. Obtaining the specificity of chronic bronchitis results in going from no comorbidity adjustment to a high comorbidity adjustment due to the interaction of the Skin 3 and Respiratory 4 comorbidity subgroups.
Another example where specificity can make an impact on whether you achieve a comorbidity adjustment is a patient with deep vein thrombosis. Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity does not provide any comorbidity adjustment, however if documentation of laterality was documented by physician or clinician, the code would then fall into Circulatory 9 and would provide at least a low comorbidity adjustment.
Unspecified codes are used when there is lack of information. Agencies should work to educate their referral sources on the importance of obtaining details that allow them to record more precise codes whenever a specific code is available so the agency can receive the appropriate reimbursement that reflects the amount of care the patient requires.
The CY2023 low comorbidity adjustment subgroups along with the high comorbidity subgroups include the diagnoses within the comorbidity adjustments. The descriptions of the adjustments can be found at the CMS HHA Center Webpage.
| Q1 to Q3 2022 Corridor Top 10 Diagnosis Codes by Clinical Grouping | |
| PDGM Clinical Group/Top 10 Dx Codes | Diagnosis |
| MS_REHAB | Code Description |
| Z47.1 | Aftercare following joint replacement surgery |
| Z47.89 | Encounter for other orthopedic aftercare |
| Z47.81 | Encounter for orthopedic aftercare following surgical amputation |
| M17.0 | Bilateral primary osteoarthritis of knee |
| S72.002D | Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing |
| S72.001D | Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing |
| I89.0 | Lymphedema, not elsewhere classified |
| S72.142D | Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing |
| M48.061 | Spinal stenosis, lumbar region without neurogenic claudication |
| S72.141D | Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing |
| MMTA_CARDIAC | |
| I11.0 | Hypertensive heart disease with heart failure |
| I13.0 | Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I10 | Essential (primary) hypertension |
| I12.9 | Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris |
| I48.91 | Unspecified atrial fibrillation |
| I48.0 | Paroxysmal atrial fibrillation |
| I13.2 | Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease |
| I21.4 | Non-ST elevation (NSTEMI) myocardial infarction |
| I12.0 | Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease |
| WOUND | |
| E11.621 | Type 2 diabetes mellitus with foot ulcer |
| Z48.00 | Encounter for change or removal of nonsurgical wound dressing |
| Z48.01 | Encounter for change or removal of surgical wound dressing |
| I87.2 | Venous insufficiency (chronic) (peripheral) |
| L03.115 | Cellulitis of right lower limb |
| L03.116 | Cellulitis of left lower limb |
| L89.154 | Pressure ulcer of sacral region, stage 4 |
| L89.152 | Pressure ulcer of sacral region, stage 2 |
| L89.312 | Pressure ulcer of right buttock, stage 2 |
| T81.31XD | Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter |
| NEURO_REHAB | |
| G20 | Parkinson’s disease |
| I69.354 | Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side |
| I69.351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side |
| G30.9 | Alzheimer’s disease, unspecified |
| G35 | Multiple sclerosis |
| G93.41 | Metabolic encephalopathy |
| I69.398 | Other sequelae of cerebral infarction |
| G30.1 | Alzheimer’s disease with late onset |
| I69.320 | Aphasia following cerebral infarction |
| S06.5X0D | Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter |
| MMTA_RESP | |
| U07.1 | COVID-19 |
| J44.9 | Chronic obstructive pulmonary disease, unspecified |
| J44.1 | Chronic obstructive pulmonary disease with (acute) exacerbation |
| J18.9 | Pneumonia, unspecified organism |
| J43.9 | Emphysema, unspecified |
| J96.01 | Acute respiratory failure with hypoxia |
| J96.21 | Acute and chronic respiratory failure with hypoxia |
| J18.8 | Other pneumonia, unspecified organism |
| J69.0 | Pneumonitis due to inhalation of food and vomit |
| J44.0 | Chronic obstructive pulmonary disease with (acute) lower respiratory infection |
| MMTA_ENDO | |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| E11.9 | Type 2 diabetes mellitus without complications |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia |
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy |
| E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| E03.9 | Hypothyroidism, unspecified |
| E11.69 | Type 2 diabetes mellitus with other specified complication |
| E11.649 | Type 2 diabetes mellitus with hypoglycemia without coma |
| E11.43 | Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy |
| MMTA_GI_GU | |
| N39.0 | Urinary tract infection, site not specified |
| N17.9 | Acute kidney failure, unspecified |
| N40.1 | Benign prostatic hyperplasia with lower urinary tract symptoms |
| K92.2 | Gastrointestinal hemorrhage, unspecified |
| N31.9 | Neuromuscular dysfunction of bladder, unspecified |
| N30.00 | Acute cystitis without hematuria |
| K52.9 | Noninfective gastroenteritis and colitis, unspecified |
| N13.6 | Pyonephrosis |
| K74.60 | Unspecified cirrhosis of liver |
| N30.01 | Acute cystitis with hematuria |
| MMTA_INFECT | |
| A41.9 | Sepsis, unspecified organism |
| C61 | Malignant neoplasm of prostate |
| D51.0 | Vitamin B12 deficiency anemia due to intrinsic factor deficiency |
| D64.9 | Anemia, unspecified |
| A41.51 | Sepsis due to Escherichia coli [E. coli] |
| D50.9 | Iron deficiency anemia, unspecified |
| D62 | Acute posthemorrhagic anemia |
| C90.00 | Multiple myeloma not having achieved remission |
| A04.72 | Enterocolitis due to Clostridium difficile, not specified as recurrent |
| C67.9 | Malignant neoplasm of bladder, unspecified |
| MMTA_AFTER | |
| Z48.812 | Encounter for surgical aftercare following surgery on the circulatory system |
| Z48.815 | Encounter for surgical aftercare following surgery on the digestive system |
| Z48.3 | Aftercare following surgery for neoplasm |
| Z48.816 | Encounter for surgical aftercare following surgery on the genitourinary system |
| Z48.811 | Encounter for surgical aftercare following surgery on the nervous system |
| Z48.817 | Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue |
| Z48.813 | Encounter for surgical aftercare following surgery on the respiratory system |
| Z48.03 | Encounter for change or removal of drains |
| Z48.22 | Encounter for aftercare following kidney transplant |
| Z48.89 | Encounter for other specified surgical aftercare |
| MMTA_OTHER | |
| G89.29 | Other chronic pain |
| I95.1 | Orthostatic hypotension |
| E87.1 | Hypo-osmolality and hyponatremia |
| G40.909 | Epilepsy, unspecified, not intractable, without status epilepticus |
| M81.0 | Age-related osteoporosis without current pathological fracture |
| E86.0 | Dehydration |
| G89.4 | Chronic pain syndrome |
| E53.8 | Deficiency of other specified B group vitamins |
| E87.6 | Hypokalemia |
| E43 | Unspecified severe protein-calorie malnutrition |
| COMPLEX | |
| Z46.6 | Encounter for fitting and adjustment of urinary device |
| Z43.5 | Encounter for attention to cystostomy |
| Z45.2 | Encounter for adjustment and management of vascular access device |
| Z43.6 | Encounter for attention to other artificial openings of urinary tract |
| Z43.3 | Encounter for attention to colostomy |
| Z43.1 | Encounter for attention to gastrostomy |
| Z43.2 | Encounter for attention to ileostomy |
| Z43.0 | Encounter for attention to tracheostomy |
| K94.23 | Gastrostomy malfunction |
| T83.510D | Infection and inflammatory reaction due to cystostomy catheter, subsequent encounter |
| BEHAVE_HEALTH | |
| F03.90 | Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety |
| F03.91 | Unspecified dementia, unspecified severity, with behavioral disturbance* |
| F41.9 | Anxiety disorder, unspecified |
| F32.A | Depression, unspecified |
| F20.9 | Schizophrenia, unspecified |
| F31.9 | Bipolar disorder, unspecified |
| F20.0 | Paranoid schizophrenia |
| F32.9 | Major depressive disorder, single episode, unspecified |
| F25.0 | Schizoaffective disorder, bipolar type |
| F41.1 | Generalized anxiety disorder |
** No longer valid after ICD-10 update in October 2022
More than ever before, correct and specific ICD-10 coding is required to receive the reimbursement you deserve under the Patient-Driven Groupings Model (PDGM). Boost compliance, save your staff valuable time and reduce administrative costs by contacting Corridor to access our coding and clinical documentation review.
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